with the Credentials Committee to formulate a For Cause FPPE tied to the reappointment ( e . g . monitoring compliance with rule indicators for a defined period ). e . Escalation of or plans to address significant quality concerns will be pursuant to the Medical Staff Credentials Policy
3 . INDICATORS FOR REFERRAL : ( Appendix A ) a . Indicators for Referral is a set of measures that may trigger a referral to the QPRC to screen for possible quality of care concern . The indicators may be general ( i . e . applicable to most physicians / APPs or may be specialty specific ). i . Development and approval : The development and maintenance of the Indicators for Referral will be a Renown Health coordinated process overseen by the Quality Department with review and input from the QPRC , CMOs , and VPMAs . The individual hospital ’ s QPRC will be responsible for including the appropriate department chairs , section chiefs or physician / APP representatives for specialty specific indicators . On an annual basis , the QPRC should review the indicator list . ii . The indicators will be categorized as triggers for the following : a ) Case review ; b ) Rate ; or c ) Rule compliance .
4 . CASE REVIEWS : ( Appendix B ) a . Individual Case Reviews should be limited to those cases that are not better assessed by rule or rate indicators , i . e . significant events , unusual or concerning trend , which require detailed medical record assessment and care evaluation . Cases primarily involving professional conduct may be referred to the appropriate Medical Staff leader or committee to review and address according to policy or code of conduct . b . Screen and initial peer review assignment : The Peer Review Coordinator ( PRC ) will screen referrals . If appropriate for peer review , the PRC and QPRC chair will assign the review to a physician / APP , section , or department . For the initial review , as peers , only physicians will review care concerns involving physicians , and APPs will review care concerns involving APPs . The reviewer may not necessarily be a member of the QPRC depending on the expertise needed . Any reviewer potential conflict of interest should be declared and addressed by the QPRC chair . All reviews should be requested on behalf of the QPRC and conducted in a confidential manner to maintain the protections of the state peer review statues . Correspondence should include the following confidentiality statement : “ Confidential and privileged information subject to the quality management program , patient safety , professional review , and / or attorney / client privileges and protections pursuant to State and federal law . Do not copy , distribute , or re-disclose .”
c . Initial Peer Review : i . The Quality Coordinators ( QCs ) and / or PRC will be responsible for creating a Situation , Background , Assessment , and Recommendation of questions to be addressed ( SBAR ) summary of key pertinent facts from the initial referral and review of the medical record . The peer review SBAR will be given to the Physician / APP , section , or department to help facilitate the review . ii . If initial review reveals no concerns , and QPRC chair reviews and agrees with the rationale , the case should be referred to the QPRC for the consent agenda . iii . If concerns are raised , the reviewer will discuss the case with the QPRC Chair and a letter of inquiry ( by email ) with clarifying questions will be sent , on behalf of the QPRC or QPRC Chair , to the physician / APP under review .